Cardio 1-2 Summary Flashcards
NYHA Classifiction
1- No Sxs w/ ordinary activity (ACEI/ARB)
2- Ordinary activity causes Sxs (Loop, Thiazides)
3- less than ordinary activities causes Sxs (Ald Antagonist, Entresto)
4- Sxs at rest (Digoxine, Dobutamine)
Define Pulsus Paradoxus
What conditions can cause it?
Inspiration causes SBP to dec >10mmHg
COST of COPD C. Pericarditis Obstructive airway SVCava obstruction Tamponade COPD
Criteria for OHOTN
What part of the criteria is most specific
Dec of HR by 30, SBP by 20, DBP by 10
HR- indicates low circulating volume
Define Osler’s Sign
Wide PP can be due to ?
Narrow PP can be due to ?
Calcified radial artery causes artificially high BP
AR
MR, MS, AS
Define Pulsus Alternans
Define Pulsus Parvus et Tardus
Changing PP amplitude due to LV dysfunction
Severe AS causing slow carotid upstroke
Define Pulsus Bisferiens
Define Spike and Dome pulse
Double wave from AS and AR
Double carotid pulse from HOCM
Normal boundaries and size for PMI
Normal duration of precordial palpitation?
5th ICS 10cm or less from midline, diameter 2-3cm
<1/2 of systole
What causes a loud S1
What causes a soft S1
Loud: THE Short PR
Tachycardia, High LA Press/CO, Early MS, Short PR
Soft: 1MC LH
1* Block, MR, Calcified MV, Late MS, High LV diastolic pressure,
What causes an S1 to vary in volume
What causes loud S2?
What causes soft S2?
VAC
Complete AV Block, V-tach, A-Fib
Soft: AS, PS
Loud: HTN, PHTN
What 4 issues can cause soft heart sounds?
What causes high pitched diastolic murmurs?
What causes low pitched diastolic murmurs?
POLE
Pulmonary effusion, Obese, Low CO, Emphysema
High: AR, PR
Low: MS, TS
What are the 6 parts of the JVP wave and what do they mean?
A wave: Atrial contraction
X descent: Atrial relaxation
C wave: TB bulge during RV systole, timed w/ carotid
X Prime: Heart base descent during ventricular systole
V wave: Passive atria filling against closed AV valve
Y descent: Early rapid atrial emptying
Lack of A-waves mean ?
Giant A-wave means ?
A-Fib, atrial stand still
Contacting atria against increased resistance
RVH, PS, TS, PHTN
Cannon A-waves mean ?
C-V waves mean ?
Contracting Atria against closed TV
AV dissociation, PVCs
Systolic venous pulsations
Regurgitating blood back into venous system in TR, makes a rapid y-wave
What does a sharp Y-descent mean?
Each small box on an EKG means ?
Each large box means ?
Constrictive pericarditis
Y > X phenomenon
- 04sec
- 2sec
EKG axis points ? hypertrophy and ? from infarcts
Normal axis range is -
Towards, Away
-30aVL - +30aVF
RVH criteria
LVH criteria
Must have RAD
No BBB
Dominant R in V1, dominant S in V5,6
Scott: Deepest S in V1,2 + deepest R in V5,6
RAE criteria
LAE criteria
P Pulmonale
R: P-wave >2.5mm in 2, 3, aVF
P Mitrale
L: P-wave >0.11s in 1, 2, aVL, V4-6 or,
Biphasic P-wave in V1
Where are Q waves normally present and where are they considered non-significant
What does the RCA supply blood to?
Normal in I, non-significant in III
2, 3, aVF Inf/Post LV RA/RV Post 1/3 of septum 70% of SA nodes 85% of PDAs AV node
What does the LAD supply?
What does the LCX supply?
V1-4
Ant 2/3 of septum
Bundle Branches
Bulk of LV/Ant surface
1, aVL, V5-6 25% of SA nodes Lat/Post LV LA 10% of PDA
What EKG changes are seen in Hyperkalemia
What EKG changes are seen in Hypokalemia
P FLEW
Peaked T, Flat P, Long PR, Elevated ST, Wide QRS
Flat UPS
Flat T, U wave, Prolonged QT, ST depression
What are the criteria for low voltage EKGs?
What are 3 drugs that can cause Prolonged QT and U waves?
Precordial leads <10mm
Limb leads <5mm
Quinidine, Phenothiazine, TCAs
How do PEs manifest on EKGs?
What is the purpose of using Holter Monitors
S1Q3T3
Pos aVR and V1
Detect arrhythmias
Relate Sxs to dysarrhythmia
Detect MIs
What does the Colour Flow on US assess for
TEEs are more sensitive and better for looking for ?
Valve regurgitation
Valve stenosis
Shunts
PEVD
Prosthetic heart valves, Emboli, Vegetations, IE, Dissection
Coronary angiography is the Gold Standard for ?, prognosis for ? and guiding therapy for ?
What information is provided by doing this procedure?
Detection/quantifying CAD
Post-MI
CABG vs PTCA vs medical therapy
Hemodynamics, Coronary anatomy, LVEF,
What drugs are used in pharmaceutical stress tests?
Inc coronary flow: Dipyridamole, Adenosine
Inc myocardial O2: Dobutamine (B1 selective)
What can cause sinus brady?
Inc HIDE Excessive vagal tone Inferior MI Drugs Hypothyroid Inc ICP
1* Block
2* Block M Type 2
2* Block W Type 1
3* Block
PR interval >0.2sec
Fixed PR and dropped QRS
Progressively longer PR until dropped QRS
No P-wave to QRS
Define Stokes-Adams attack
Criteria for RBBB
Criteria for LBBB
Syncope associated w/ brief cardiac arrest due to 3* block
Rabbit ears V1 and V2
Broad/notched R wave in V6 and aVL
Anterior Hemiblock criteria
Posterior Hemiblock criteria
A: LAD >45*
Small Q in 1 and aVL
Small R in 2, 3, aVF
P: RAD >110*
Small R in 1 and aVL
Small Q in 2, 3, and aVF
Tachycardia is greater than ?BPM and treated with ?
How are premature beats (atrial or junctional) treated?
100
Sxs= propanolol
BBs or CCBs
A-FIb beats at _BPM and is treated ?
250-350 Valsalva, Adenosine 6mg, Adenosine 12mg Rate control w/ BB, Verapamil, Digoxin Rx Conversion: procainamide, Sotalol, Amiodarone, Quinidine Electrical conversion: DC shock w/ 50J
Narrow complex tachy at 150bpm is ? until proven otherwise
MAT beats at ?BPM and is Tx w/ ?
A-flutter w/ 2:1 block
100-200bpm
Metoprolol
Define Ashman Phenomenon
Wide QRS’ after a long short R-R cycle and a Long R-R cycle in A-Fib
How is A-Fib rate controlled?
What is used for anticoagulant in paroxysmal or chronic A-Fib?
BB, Verapamil, Digoxin
Warfarin
What meds are used for A-Fib cardioversion?
Class I agent if ventricular function is normal- Procan, Propaf
Sotalol
Amiodarone
Synch’d conversion w/ Diltiazem
How are PSVTs treated?
How are Symptomatic PVCs treated?
Valsalva, Adenosine, Metoprolol, Digoxin, Verapamil
Chronic= BB, Verapamil, Digoxin, ablation
BBs
What is the most common underlying cause of V-tach?
When is an arrhythmia called VT and when is it an emergency?
CAD w/ MI
3 or more consecutive PVCs for more than 30seconds
What arrhythmia is most frequently encountered by adults who experience sudden death?
What class 1 and 3 drugs, two other classes can cause Torsades?
V-Fib
1- Quinidine
3- Sotalol
TCAs, Erythromycin
WPW EKG triad
What drug needs to be avoided and which one is used?
Tall R w/ Delta
Short PR
Long QRS
Avoid Digoxin (AV conduction slowing) Use IV procainimide
What is the commonest cause of CV morbidity and mortality?
What are the two most important pathogenetic mechanisms?
Ischemic heart dz
Atherosclerosis and Thrombosis
What are 5 major risk factors for atherosclerosis heart Dz?
Smoking, DM, HTN, FamHx, Hyperlipidemia
JNC8 HTN Guidelines
AHA Guidelines
Normal= <120 AND <80 Pre= 120-139/80-89 1= 140-159/90-99 2= 160 or more / 100 or more
Norm= <120 and <80 Elevated= 120-129 and <180 1= 130-139/80-89 2= 140 or higher / 90 or higher
What are the first and second most common causes of Secondary HTN?
How do you screen for HTN from Primary aldosteronism, Cushings, thyroid or hyperparathyroidism?
1st= CKD 2nd= Primary aldosteronism
Thyroid= TSH Hyperpara= PTH and Ca
What is the most common form of secondary HTN?
Define Fibromuscular Dysplasia
Renal Parenchyma
Condition causing stenosis and aneurysms of medium sized arteries in body, most commonly kidneys and brain
What type of pharmaceutical addition results is indicative of a sign for potential bilateral renal artery stenosis
ACEIs inhibit ? into ?
ARBs inhibit ? into ?
Rising creatinine after starting ACEI
ACEI- angiotensin 1 into 2 and bradykinin into fragments
ARB- angiotensin 2 into AT1 receptors
What is the triad of Pheo?
Familial Pheo may be associated with ?
Episodic HA, Sweating, Tachy
1/2 will have paroxysmal HTN
Multiple Endocrine Neoplasia syndrome type 2A/2B
What is the most reliable diagnostic test for Pheo?
How does hyperaldosteronism cause Secondary HTN?
24hr urine catecholamine and metanephrines
Excessive aldosterone from: Conn Syndrome (adrenal adenoma) Bilateral hyperplasia (primary hyperaldosterone)
What causes Secondary Hyperaldosteronism?
What is the classic finding in hyperaldosteronism and how is it Dx’d?
Rare renin secreting tumor
Unprovoked hyperkalemia
24hr urine aldosterone test w/ aldosterone:renin >25:1
What are the lab results for primary hyperaldosteronism?
What PE results may be seen?
Hypokalemia
Chovstek sign
Trousseaus sing
Define Cushing’s Syndrome
Define Cushing’s Disease
Synd= Excess cortisol causing increased blood volume and renin production
Dz= pituitary adenoma that over produces ACTH
How is Cushing’s Dx’d?
What are the 4 causes of Cushing’s Syndrome?
Dexamethasone suppression test
24hr urine cortisol levels
Adrenal hyperplasia/adenoma/CA
Oral steroids
What are the classic associations of hyperthyroid and hypothyroid?
Hyperparathyroid is commonly due to ? and characterized by ?
Hyper= systolic HTN Hypo= diastolic HTN
PTH secreting adenoma
Hypercalcemia
What medications have been linked w/ causing HTN?
How much alcohol intake has been associated with reducing CV morbidity and mortality
Estrogen, CCS, Cyclosporine, Erythropoietin, Pseudophedrine (OTC cold meds)
2 drinks or less per day
What is the appropriate way to document BP measurements?
When do results need to be confirmed on the contralateral arm?
Pressure, PT position, which arm and cuff size
+65, DM, Anti-HTN drugs
What is the next step if PTs BP readings are high and PT is under 30y/o?
When is ambulatory BP monitoring needed?
Take pressure on leg
White coat HTN and no end organ damage
Episodic HTN
HTN Sxs while on anti-HTN meds
The absence of a PTs BP decreasing by 10-20% during sleep is indicative of ?
When are annual BP screenings recommended?
CVD risk
40 and older w/ inc risk (130135/85-89)
Obese
Black
How often do PTs w/ BP under 130/85 and no risk factors need screenings?
How often do PTs between 3-17y/o need BP screenings?
Q3-5yrs
Annually
What test order is considered a standard part of the uncomplicated HTN work up?
What are the 5 non-pharm steps that can be taken to reduce BP
Chest x-ray
Weight= 5-20 dec DASH diet= 8-14 dec Na restriction Exercise Moderation of alcohol
What needs to be monitored when using Thiazides, Loops, ACEIs, ARBS or Alaskerine for HTN?
What lab test is used to monitor these?
Thiazide= low K and Na Loop= low K and Mg ACEI= hyper K ARB= hyper K Allask= hyper K
BMP, Chem 7
What drug classes can not be used for HTN in pregnancy?
What two are used in post-MIs?
ACEI/ARB
BB, ACEI
What drug can be added to the 3 pregnancy anti-HTN meds to prevent reflex tachy?
What two meds are reserved for HTN Tx for PTs who fail everything else?
Hydralazine
Hydralazine
Minoxidil
Define/Criteria for HTN Urgency
> 180/>120 and no end organ damage
Reduce BP over 24-48hrs
Sxs= HA, SoB, Epistaxis, Anxiety
Define/Criteria for HTN Emergency
> 180/>120 and end organ damage
Stroke, LOC, Amnesia, Crushing chest pain, Eye/Kidney damage, Dissection, UA, Pulm Edema, Eclampsi
What is the adverse effect if HTN urgency/emergency PTs have their BP decrease too much too soon?
Drugs used in HTN Urgency?
Worsening end organ ischemia
Clonidine
Captopril- use instead of Clonidine in HF
Labetalol- pregnant PTs or can’t tolerate Methyldopa
What is the most commonly used ED parenteral anti-HTN med?
What type of HTN can it NOT be used for?
Labetalol
Cocaine intox and Systolic dysfunction w/ Decomp’d HF
BP reduction goals for HTN Emergency
Compelling (Eclampsia, Pheo)- reduced to less than 140mm in first hour, (Dissection)- reduced to under 120mm
No compelling- reduce SBP no more than 25% in first hour, 160 in 4-6hrs and normal within 24-48hrs
Use of parenteral drugs is preferred
What drugs are used for HTN Emergency caused by cocaine?
What drugs are used for HTN Pulmonary Edema
IV Lorazepam/Diazepam
IV Nitro (first line) IV Nicardipine (favorable for systolic dysfunction and pregnant PTs w/ pre-eclampsia)
What drugs are used in acute MI induced HTN emergency?
IV Nitro (first line) IV Metoprolol
Adverse effects, C/I and Caution of using Sodium Nitroprusside
Cyanide toxicity, Methemoglobinemia
C/i- renal/hepatic failure
Caution- Inc ICP
Adverse effects and Caution of using Nitro
Tachyphylaxis, Methemglobinemia
Caution- Inc ICP
Adverse effects and Caution of using Hydralazine
Reflex tachycardia, HA
Caution: Angina/MI, Inc ICP, Dissections
Adverse effects and C/I of using Enalaprilat
Hyperkalemia, Renal insufficiency
C/i- Pregnancy, Renal stenosis, Angioedema
Adverse effects and Caution of using Nicardipine
Reflex tachy, N/V, HA
Caution- Angina/MI, HF
Adverse effects and Caution of using Esmolol or Labetalol
Bronchospasm, HF exacerbation, Bradycardia
Caution- Acute HF, Asthma, Heart Block
Definitive Tx for AVRT is ablation, what meds can be used for management and refractory cases?
Manage= BB, Diltiazem, Cerapamil
Refractory= Flecainide, Propafenone
What ABX can’t be used as monotherapy for endocarditis?
What 3 drugs can be used prior to PCI as an anti-thrombolic, reduces morbidity and reduces bleed risks?
Gentamicin, must be used in combo
ASA, Bivalirudin, Ticagrelor
What are the three ADP receptor inhibitor drugs used for anti-platelet therapy?
What drugs are first ling options for HTN Emergencies?
Clopidogrel, Ticagrelor, Prasugrel
IV Labetolol- a/b blocker
Nitroprusside
Nicardipine
Urapidil- blocks peripheral a1 receptors)
How are PTs that are admitted for HTN emergencies weaned down and prepared for discharge?
What drug can be used for HTN emergencies in pregnancy that is given IV?
PO Labetalol
PO DHP CCB
IV Furosemide
Nicardipine
What are the key findings to hint a PT has Fibromuscluar Dysplasia?
What is the other main cause of renal artery stenosis?
Renal and Abdominal bruits
Atherosclerosis in older PTs
What medication can be used in systolic HF and reduces mortality and prevents hypokalemia?
Once this class of drug has started use, how long is it used for?
Eplerenone
Mineral corticoid receptor antagonists are used indefinitely
When is a Pheo Dx highly indicative?
These are commonly mis-Dx as ?
HTN that is resistant to meds or paroxysms of HA, palpitations, pallor or diaphoresis
Panic D/os
PT w/ systolic CHF can be given what med to improve Sxs and reduce long term mortality?
What can be given if the PT has diastolic CHF and still provide Sx reduction and improve mortality?
Carvedilol
Spironolactone
What are Event Monitors AKA and when are they used?
Loop recorders
Record intermittent episodes during long periods (weeks to months), useful for patients with less frequent symptoms
What is the primary indicator a PT needs an ICD?
What drug class is the first line therapy for managing angina and HF from exercise induced ischemia?
Sustained VT/VF in PTs w/ organic heart dz
BBs- Metoprolol
PTs taking Warfarin are more likely to start spontaneous bleeding when INR moves in ? direction?
What is the difference in ANP and BNP?
Increases
ANP- stimulated from stretch, no reduction in PL/AL
BNP- reduces PL, AL and signals for diuresis
Used for Dx
What are 2 conditions that can cause BNP levels to decrease?
What can cause levels to increase?
Obesity
Constrictive pericarditis
Age
Renal Dz
African American PTs w/ HTN that have reduced GFR are given ? class drugs for Tx?
What is the next DOC for PTs with A-Fib and are unresponsive to BBs?
ACEIs
Digoxin
What aortic issue is associated w/ Quincke sign and the head bob?
What are the 3 c/i for giving an ACEI in early ASx systolic HF?
AR
Hx of edema
HOTN
Bilateral renal stenosis
What are the DOC for treating acute MAT?
What Tx is avoided?
IV Diltiazem, Verapamil or Metoprolol
Conversion
What drugs are used for anticoagulation therapy before/after conversion for A-Fib?
What heart issue can develop from the last month of pregnancy to 5mon post-delivery?
Dabigatran, Rivaroxaban, Apixaban, or Endoxaban, or Warfarin with an INR of at least 2
Peripartum cardiomyopathy
How is peripartum cardiomyopathy treated?
What is the most common cause of HF w/ preserved EF?
Furosemide
Sulfa allergy= Ethacrynic acid
HTN
What are 3 conditions that can cause high output HF?
What microbe causes myocarditis?
Obesity, Anemia, Renal Dz
Coxackie B Virus
What rhythm is associated with alcohol induced dilated cardiomyopahthy?
A second murmur can develop with AR and exist with what other murmur/cardiac issue?
A-Fib
Austin Flint- MV rumble heard at LV apex
What drug classes are used for CKD PTs w/ HTN?
What can be used for Diabetics w/ HTN?
ACEI/ARB
AACT
What drugs are first line agents for rate control in non-HOTN A-Fib?
What drug is third in line?
Esmolol, Metoprolol, Verapamil, Diltiazem
Digoxin
PT w/ new onset A-Fib are considered good candidates for conversion and are anti-coagulated with ? drugs?
Direct acting PO anti-coags
dabigatran, rivaroxaban, apixaban, or edoxaban
WPW A-Fib is Tx w/?
WPW wide complex is treated w/ ?
Ibutalide
Procainamide
IE microbe if on native valve, IVDA, Colon CA, Prosthetic valve?
The LMNOP algorithm is for what two Tx?
Native: Strep V
IVDA: Staph A
Colon CA: Strep Bovis
Prosthetic: Staph Epidermis
Decomp HF
Pulmonary edema
Define Diastolic Dysfunction
Define Systolic Dysfunction
Dec end diastolic volume, ineffective ventricular filling
Ineffective ventricular emptying
HFrEF
HFpEF
What is the ‘pure form’ of HF?
Systolic dysfuntion
Dystolic dysfunction
R sided
Define Preload
Define Afterload
Define Contractility
Wall tension at diastole end
Wall tension during contraction
Property of heart muscle that accounts for strength of contraction and independent of AL/PL
Reduced EF= _%
Gray zone= _%
Preserved EF= _%
<40%
40-50%
> 50%
S/Sxs of HF w/ reduced EF
Dyspnea, Paroxysmal, Nocturnal
Dilated LV
Elevated LV filling pressure
Primary systolic dysfunction
What are the 3 parts that contribute to HF?
Impaired contractility (HTN,AS)
Inc AL
Impaired ventricle relaxation/filling- vol overlaod, AR, MR, DCM
Once cardiac remodeling has occurred, there is ? which triggers what 3 systems which all lead to what end result?
Dec EF
RAAS, Adrenergic and Hypothalamic neuro-hypophyseal systems
Inc water retention and plasma volume
HFrEF hypertrophy can lead to the development of ? murmur?
2nd MR
What is the LMNOP of decomp HF?
What drug is used for PTs in decomp HF and which one is never used??
Lasix, Morphine, Nitrates, O2, Position (not supine)
Dobutamine
Never use BBs
What would be two c/i for giving CCBs?
How long after starting a diuretic or an ACEI does monitoring need to occur for potassium levels?
Edema, Constipation
Diuretic- 4-6wks
ACEI- 1wk
What is the TIMI score used for and how is it calculated?
65 or older 3 or more CAD risk factors (FamHx of CAD, HTN, Hyper cholesterol, Diabetes, Smoker) CAD/Stenosis 50% or more ASA use in past 7 days 2 or more angina episodes in past 24hrs ST segment changes 0.5mm or more Pos cardiac markers
0-2 Low
3-4 Mod
5 or higher High risk of 14 day mortality, New/Recurrent MI or severe recurrent ischemia requiring revascularization
What regurgitation can happen with HCM?
What type of microbe can cause endocarditis from poor dental hygiene?
MR
Step viridians
What 3 Sxs can be classified as a symptom of HTN emergency?
Pulsus alternans is a common Sxs from what type of HF?
Chest pain, Dyspnea, Neuro deficits
L ventricular systolic HF
What is the gold standard for Dx myocarditis?
How do atypical MIs present?
Endomyocardial biopsy
Older, Female, DM, HTN, Post-heart transplant
Aortic root dilation is usually associated with ? congenital d/o and type of valve?
Failure to carry out conversion properly can lead to the development of ? arrhythmia?
Turners, Bicuspid
V-Fib
How does nitroprusside work?
ANP released by increased stretch is associated with what two results?
Arterial and venous dilator by increased cyclic GMP that activates Ca sensitive K channels in membranes
Increased vascular permeability
Rapid fluid shift into interstitial space
What labs need to be drawn prior to starting PTs on statins?
AS in young PTs mean ?
AS in older PTs means?
LFTs
Calcified bicuspid
Calcified tril-eaflet aorta
What is Digoxin’s MOA?
What effect does it exert?
What are the s/e?
Inhibits Na/K/ATPase
Dec AV conduction and contractility
N/V/D
Yellow vision
What is the most serious reaction that can come out of Amiodarone use?
Hemodynamically unstable bradycardia in a PT with a recent Hx of viral illness can be due to ?
How is it Tx?
Interstitial lung Dz- SoB, dry cough, R sided HF
Myocarditis
Inc HR w/ inotropic support/pacing
What can PAOP measurements be used to determine?
What is the most common cause of non-ischemic cardiomyopathy in Latin America?
LV failure, MS, pathologies that inc LA pressure
Chagas myocarditis
What drug class is the DOC for PTs w/ HTN, DM or Microalbuminemia
What are 3 ends results of Rheumatic heart Dz?
ACEI
MS, A-Fib, Pulmonary Edema
What movements increase and decreases HOCM?
What microbe causes acute Rheumatic Fever?
Valsalva and Standing
Dec w/ squatting
GAS- Strep Pyogenes
What are two potential complications that can arise post-MI?
Mesenteric ischemia is similar to ?
VSD from septal rupture
MR
Free wall rupture turning into tamponade
Atherosclerosis of stable angina
What are the water shed areas affected by mesenteric ischemia and what arteries supply them?
What is the most common cause of sudden cardiac death after MIs?
Splenic flexure- superior mesenteric artery
Rectosigmoid junction- inferior meseneric artery
Ventricular arrhythmia
Viral myocarditis can lead to ? and presenting as ?
Define Cor Pulmonale
DCM, dec systolic function and chamber dilation
Severe lung Dz elevated pulmonary artery pressure pushes back to the RV and causes failure
What are five causes of DCM?
How does the atherosclerosis process begin?
Alcohol, Pregnancy, Coxsackie, Idiopathic, Genetic
Lipids and inflammation accumulation causes turbulent flows and intimal damage
? is an indication for renal artery stenting?
What drug class can be given to ASx or Sx LV systolic dysfunction and reduce mortality and hospitalization?
CHF
ACEI
What microbe is associated with endocarditis and colonic neoplasm?
What is the DOC given to all PTs w/ systolic HF?
S Bovis biotype
ACIE and BB w/ Metoprolol Succinate the DOC
Define Conn Syndrome
How does it present?
Common cause of Secondary HTN
HTN, hypokalemia, metabolic alkalosis
What are the two Sxs of HCM that present if death isn’t first?
How do NSAIDs worsen HF?
Dyspnea and chest pain
Na retention Negative ionotrope Cardiotoxicity Inc renal dysfunction Impaired ACEI/Diuretics
What are the major Framingham criteria?
What are the minor Framingham criteria?
RN PATCH
Rales, Neck vein distension, Paroxysmal dyspnea, Acute pulm edema, Third heart sound, Cardiomegaly, Hepatojugular reflex
HaD PANTs
Hepatomegaly, Dyspnea w/ exertion, Pleural effusion, Ankle edema, Nocturnal cough, Tachy +120
HF Dx w/ 2 major or, 1 major and 2 minor
What are the cardinal Sxs of HFrEF?
What’s the difference between Ecentric and Concentric hypertrophy?
Dypnea and Fatigue
Ec- inc ventricle chamber radius and thickness
Con- inc wall thickness w/out proportional dilation
What does the HEART FAILED acronym stand for?
Precipitating factors of HF HTN Endocarditis/environment (heat) Anemia Rheumatic/valve dz Thyrotoxicosis Failure to take meds Arrhythmia Infection/infarct Lung problem Endocrine (pheo, hyper aldost) Dietary indeiscretion
HFrEF ventricular hypertrophy and Remodeling occur due to ?
What are the 5 neuro-hormonal compensatory mechanisms of HFrEF?
Hypertrophy- press and vol overload
Remodel- eccentric and concentric remodel
Natriuretic peptides Endothelin Adrenergic nervous system RAAS ADH
What are the 5 commonest causes of CHF?
CAD Idiopathic seen as DMC Valve- AS, AR, MR HTN Alcohol as DMC
What are the less common causes of CHF?
GEMTIPI
Genetic- Freidrichs ataxia, hereditary HCM
Endocrine- hyperthyroid, DM, acromegaly
Metabolic- thiamine/selenium deficiency
Toxic- adriamycin, doxorubin, radiation, uremia, cathchol
Infectious- Chaga, Coxsackie, HIV
Peripartum
Infiltrative- sarc/amyloidosis, hemochromatosis
What are the two cardiac responses to myocardial stress?
What are the systemic responses to ineffective circulating volume?
Pressure overload leads to hypertrophy (HTN)
Volume overload leads to dilation (AR)
Activation of sympathetic NS and RAAS-
Na/H20 retention, Inc HR/contractility, Inc AL
Long term CHF management steps
O2, Bed rest, Head elevation
1- Na/Fluid retention control w/ daily weights - Furosemide w/ or w/out Metalozone
2- Vasodialtor to inc PL and dec AL- ACEI, Hydralazine and Nitrates, Amlodipine (DCM), ARBs
3- Ionotropics- Digitalis (CHF w/ A-Fib)
4- BB (class 2-4), Carvedilol (Class 2-4), CCBs, Amiodarone (anti-arrhythmic DOC)
What are the risk factors for DCM?
CRIMINATED FIP Collagen vascular dz Radiation Idiopathic Metabolic Infectious Neuromuscular Dz Alcohol Toxic Endocrine Drugs- chemo/Adriamycin Familial Inflammatory Peripartum
What are the clinical manifestations of DCM?
What tests are done?
CHF, Systemic/Pulmonary Emobli, Arrhythmias, Sudden death
ECG, CXR, Echo, Endomyocardial biopsy, Angiography
Endomyocardial biopsies can be used to Dx what 2 Dzs?
RCM, Myocarditisq
How is DCM managed?
Treat CHF, BB, ACEI
Anti-coag w/ coumadin- absolute if A/Fib/embolus Hx or if EF <20%
Tx arrhythmias
Imms- Influenza and Pneumococcus
Surgery- transplant, LVAD, volume reduction surgery, cardiomyoplasty (latissimus dorsi wrap)
What are the hallmark signs of HOCM?
Pulses- rapid upstroke, bifid pulse
Triple apical impulse
Normal/Paradoxically split S2
S4
How investigatory tests are ordered for HOCM?
What is the most reliable risk factor?
EKG: Prominant Q waves or Tall R in V1
Echo
Cardiac cath
Survived cardiac arrest/Sustained VT
What is the most common cause of restrictive cardiomyopaty?
How is it treated?
Amyloidosis
As CHF
What is the most common microbe to cause IE in spontaneous bacterial endocarditis on an abnormal valve or MVP?
What causes IE, Group D Strep and Spontaneous Bacterial endocarditis?
Strep viridians
Entercoccus
What microbe is usually R sided and catheter associated sepsis?
What microbe is most likely to infect a prosthetic valve?
Staph A
Staph epidermis
What causes a high risk for IE in cardiac lesions?
What causes moderate risk for IE?
What is the frequency of valve involvement from IE?
Prosthetic valve, Previous IE, Congenital cyanotic dz, surgical pulmonary shunts
Congenital cardiac malformations, Acquired valve dysfunction, HCM, MVP w/ MR, Thick leaflets
MATP
What microbe causes Rheumatic Fever and how does it present?
GAS that later effects MV
Lymphadenopathy, Fever, Sore throat
What are the major/minor Jones criterias for Rheumatic Fever?
Major: Pancarditis, Polyarthritis, Sydenhams chorea, Erythema Marginatum, Subcutaneous nodules
Minor: Prev Hx of RF/RHDz, Polyarthralgia, Inc ESR/CROP, 1* Block, Fever plus
AS management
When is surgery indicated
ASx= serial echo, avoid heavy exertion, IE prophylaxis,
Avoid nitrates, dilators and ACEIs
Angina, Syncope, CHF
Progressive LV dysfunction
AV replacement, Balloon valvuloplasty
What drugs are used for AR to reduce AL?
What drugs can be used to treat CHF from AR?
Nifedipine, ACEI
Digoxin and diuretics
When is surgery indicated for AR?
What surgical procedures are done for AR?
LV failure
LVEF <55% at rest or EF fails to inc w/ exercise
Replacement- Ross procedure
Reapire- rare, annuloplasty for annular dilation
What are the 4 signs of chronic AR?
Pulses- DD CQT Hills (fem-brachial difference of >20mm
Precordial palpitation- having apex from volume overload
Precordial auscultation- soft S1/2, S3, Austin Flint, ejection
Acute AR- PTs present w/ CHF, Tachy, Soft S1, Soft/absent S2, Early diastolic murmur, preclosure of MV
When is surgery mandatory for MS?
Closed commisurotomy
Balloon vavluloplasty based on TTE
Open commisurotomy- best
Repalcement- immobile leaflet, calcified, severe subvalvular dz, MR
What signs will be seen in TS/TR?
Prominant A- TS
Larve V/CV waves- TR
Positive HJR and Kussmaul sign
JVP waves for tamponade?
What is becks triad?
X descent only, Absent Y
HOTN, Inc JVP, Muffled heart sounds
